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First name

Last name

Date of Birth

Month

Day

Year

Phone

Address

Are you currently using products containing Retin A or Retinol?

Yes

If yes, please specify...

Are you currently taking any antibiotics?

Yes

If yes, please specify...

Do you have any allergies?

Yes

If yes, please specify...

Do you have or have had any of the following conditions in the past year? Please check all that apply.

High Blood Pressure

Seizures

Stroke

Pregnancy

Diabetes

Any kind of heart condition

Pacemaker implant

Metal implants, screws or prostheses

Epilepsy

Multiple sclerosis

Muscular condition

Contact dermatitis, other skin disease

Inflammation, infection or tumor

Cancerous lesions

NONE

If you checked any of the above, please specify...

Have you had any recent illness?

Yes

If yes, please specify...

By checking this box, I certify that the information I have provided regarding my health, medical history, medications, and current conditions is true, complete, and accurate to the best of my knowledge.

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First name

Last name

Date of Birth

Month

Day

Year

Phone

Address

Are you currently using products containing Retin A or Retinol?

Yes

If yes, please specify...

Are you currently taking any antibiotics?

Yes

If yes, please specify...

Do you have any allergies?

Yes

If yes, please specify...

Do you have or have had any of the following conditions in the past year? Please check all that apply.

High Blood Pressure

Seizures

Stroke

Pregnancy

Diabetes

Any kind of heart condition

Pacemaker implant

Metal implants, screws or prostheses

Epilepsy

Multiple sclerosis

Muscular condition

Contact dermatitis, other skin disease

Inflammation, infection or tumor

Cancerous lesions

NONE

If you checked any of the above, please specify...

Have you had any recent illness?

Yes

If yes, please specify...

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Created with

ebs | CONSENT FORM